Analysis Hydraulic Winch, the Remote Stop Device, and Associated Control Valves The flow of pressurized hydraulic oil in and out of the hydraulic motor is controlled via a control valve. It has three positions: up and down which control direction of winch rotation (i.e. paying out or hauling in); and a central, neutral position. In the neutral position, no oil flows into the hydraulic motor and because of an hydraulic lock, it is not allowed to turn. The control valve has an internal spring which automatically returns it to the neutral position when the handle of the valve is released. The winch control valve on the StarQueen was found to be in a substandard condition. The valve had become sticky and hard to move; its internal resetting spring did not have sufficient tension to return the valve to neutral. Two external springs had been fitted in a makeshift arrangement to increase the resetting force, but these too had eventually become ineffective. In the end, since the hold-to-run-control could not have been used to regulate the valve, it had been disconnected. The hydraulic winch controls were also controlled by a by-pass valve on top of the motor. This valve appears to have been installed to assist single-handed operation of the net launch and it cannot be considered a remote control device similar to the hold-to-run-control. When utilizing this by-pass valve, there is no hydraulic lock, and the winch can freewheel in either direction. The hold-to-run-control is a spring loaded, remote means of regulating the control valve. When it is pressed down by the operator's foot, it pulls the handle of the control valve into the up position and turns the winch in the hauling in direction. When pressure is taken off the hold-to-run-control (i.e. the operator removing his foot), an internal spring in the control valve returns it to the neutral position, and the winch stops turning. During the hauling in process, the fisher is required to have his hands free to remove fish caught in various sections of the net and to arrange the stow and net evenly on the drum. Towards this end, fishing vessels like the StarQueen are fitted with the hold-to-run lever - a remote, foot-controlled device - that permits intermittent, start and stop process. In the event of an accident or an unforeseen occurrence, releasing the hold-to-run control will immediately stop the winch, thereby preventing injury. This is particularly important in one-person operated fishing vessels, which are common in the West Coast fishing industry. Paying out a fishing net into the water is done most often by allowing the winch to freewheel. To accomplish this, the control valve is set to neutral and the bypass valve turned to open. The weight of the net and water friction force the winch to turn and quickly pay out. Paying out can also be carried out under load by putting the control valve on stroke and closing the bypass valve. The winch now turns under the influence of the hydraulic pressure; however, this is much slower than the freewheeling mode. Protective Clothing According to the Occupational Health and Safety Regulations of the B.C. Workers' Compensation Board, paragraph 8.10 (2) (a), If there is a danger of contact with moving parts of machinery, the clothing of the worker must fit closely about the body. The owner of the vessel was wearing bib style rain pants and a rain jacket over a tee shirt and sweat pants. This protective rain gear was loose fitting, and there is no indication of the open sleeves or flaps of his jacket having been tightly secured to his body. He was working in very close proximity to rotating machinery, where wire rope, nylon rope, and fish net were in the process of being stowed. In all probability his loose clothing became entangled in the net, ropes, or machinery and he was drawn into the turning winch drum. Checkered Aluminum Deck Fishers in the local industry prefer to wear rubber deck boots which have flat, flexible soles. The efficacy of diamond-patterned decks in increasing the amount of grip between an operator's boot and the deck surface on fishing vessels is questionable because the checkered surface actually reduces the amount of contact area between the sole of the boot and the deck. There are anti-skid mats available which offer better traction when placed over potentially slippery surfaces. The StarQueen had no such anti-skid mats fitted over its working deck area. Maintenance Standards for Deck Equipment on Fishing Vessels Though the StarQueen was relatively new (having been purchased in 1995), some of the deck machinery had not been well maintained, and some elements had fallen into a state of disrepair. There were examples of jury-rigged and makeshift gear; the emergency stop/hold-to-run control had been disconnected, and hydraulic oil had leaked from machinery, on deck. Being under 15 GRT, the StarQueen was exempted from quadrennial inspections by Transport Canada, Marine Safety (TCMS). However, it had to comply with all applicable conditions and regulations of the Canada Shipping Act and was subject to spot checks and random inspections by TCMS. These inspections, however, did not include occupational health and safety issues, which are under provincial jurisdiction. In B.C., the Workers' Compensation Board has jurisdiction over work places and equipment aboard vessels engaged in the business of fishing. Towards that objective, WCB conducts random inspections on fishing vessels, gives educational presentations, and issues Hazard Alerts to educate fishing vessel operators of dangers. Potentially hazardous and unsafe conditions are effectively targeted for corrective action. Accident The fishing gear consisted of a trawl net attached to a wire warp, which was in turn fixed securely to the winch drum. The condition of the wire warp was sub-standard because the lay of the wire had opened and loose strands were protruding. The fishing net had been paid out until the drum was most probably completely empty. The operator was wearing loose-fitting protective rain gear, and it is possible that he was standing in between the sides of the drum, preparing to guide the net as it was being hauled in. As the drum was turning, the sharp strands of wire probably caught his loose sleeve or jacket, and pulled him in. Torn portions of his jacket were found entwined in between the turns of wire rope and the drum. Boots, hat, and the remainder of the jacket were found at various locations on the after deck. The control valve was observed to be leaking and the working deck was found to be covered with hydraulic oil and was quite slippery. The operator was not wearing boots when he was found and it is possible that he had slipped on this oily surface and become entangled in the fish net as it was being reeled in. Since the hold-to-run-control had been disconnected (and also because he was working alone), once he had lost his footing, there was no way of stopping the winch. The hold-to-run-control had been disconnected. There was thus, no automatic remote means of stopping the winch in the event of the operator becoming incapacitated. The control valve for the hydraulic winch did not move freely and it did not automatically return to the neutral or stop position. With no automatic resetting action available, the control valve would remain where it was positioned, and the winch would continue to turn until the control valve would be brought back manually to the neutral position. The winch continued to turn unchecked, once the owner/operator left the control stand to work the deck. It is probable that the owner/operator's loose clothing became entangled in the net or warp and that he was drawn into the turning winch drum.Findings as to Causes and Contributing Factors The hold-to-run-control had been disconnected. There was thus, no automatic remote means of stopping the winch in the event of the operator becoming incapacitated. The control valve for the hydraulic winch did not move freely and it did not automatically return to the neutral or stop position. With no automatic resetting action available, the control valve would remain where it was positioned, and the winch would continue to turn until the control valve would be brought back manually to the neutral position. The winch continued to turn unchecked, once the owner/operator left the control stand to work the deck. It is probable that the owner/operator's loose clothing became entangled in the net or warp and that he was drawn into the turning winch drum. The control valve was leaking, and the spreading of hydraulic oil over a large area of the after deck made it slippery. No anti-skid matting was laid out over the working deck behind the operator's stand. The owner/operator was working alone and after the accident, had no means of raising the alarm or calling for help. At some time, external springs had been fitted to aid the control valve internal resetting spring; however, these were disconnected at the time of the accident.Findings as to Risk The control valve was leaking, and the spreading of hydraulic oil over a large area of the after deck made it slippery. No anti-skid matting was laid out over the working deck behind the operator's stand. The owner/operator was working alone and after the accident, had no means of raising the alarm or calling for help. At some time, external springs had been fitted to aid the control valve internal resetting spring; however, these were disconnected at the time of the accident. Safety Action Action Taken by Transport Canada As a result of the numerous accidents on board fishing vessels many of which have been the subject of TSB investigations and recommendations Transport Canada has appointed Small Vessel Inspectors in its offices to inspect this class of vessel. Further, it is in the process of forming a Small Vessels Group, which will carry out spot checks and random inspections on all vessels below 60 GRT. Action Taken by the Workers' Compensation Board of British Columbia The Workers' Compensation Board (WCB) of British Columbia entered into a Memorandum of Understanding (MOU) with Transport Canada Marine Safety, in May 2001. The MOU demarcates areas of jurisdiction and also establishes areas of joint responsibility, as well as the sharing and mutual exchange of acquired information on a continuous basis. The WCB is also actively involved in disseminating safety information to and educating the fishing community of British Columbia. The goal is to educate all industry participants on long-term economic advantages of good maintenance; requirements for safe working practices; and the need to comply with appropriate provincial and federal regulations.